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;. Waste Tire Sui .ay 8c nspectlon Report Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 3 5 8 9 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey___ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> p_--- -- 1 - Inspection Type (Fill one) <br /> ffi - -- <br /> 6 LA <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: U 1 C u{,+ O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _S _, Inspected By Inspector <br /> Physical Address ^ 1 RLQ 63 C <br /> "�""IIIIWWWW <br /> Inspection Date <br /> Time In Time Out I <br /> Business Rep Title 0 AM 0 Q AM <br /> 0 PM V 45 PM <br /> U 11 V11;\S -- W Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l Q Active Q Passenger 0 Generator 0 Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> O O Inactive 19 Truck <br /> Longitude - O Planned 4k OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder S Other DA,I <br /> --------- --- -- -- — ------ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS ;in Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ; Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q 1 Other: § <br /> Comments C17n�\ Xu�)` 1 u L L <br /> action Form Included: Q <br /> Comments Included: <br /> ine ep s Slg at6e �� 'n)L'�' <br /> hone Number Inspe is Signature Phone Number j <br /> INSTRUCTION O BACK Correct:* Incorrect: Fe1 <br /> E XIAMIPILIEI 31Tr72 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />